Acute mediastinitis is life-threatening and usually results from a perforated esophagus, postcardiac

procedure, or trauma. Oral infections can also result in organisms travelling through the neck into the

mediastinum along fascial planes. These infections can travel as quickly as necrotizing fasciitis does in

other parts of the body and should be addressed immediately. A wide variety of organisms can cause

mediastinitis. Patients will have chest pain, dyspnea, and fevers. Radiographic films may show

pneumomediastinum or pneumothoraces. If an esophageal perforation is suspected, an esophagogram

should be performed. Treatment is broad-spectrum antibiotics and surgical drainage via a cervical

incision and/or thoracotomy. Quick debridement and drainage are keys to patient survival. Minimally

invasive approaches to the chest may be adequate, but surgeons should have a low threshold to perform

a posterolateral thoracotomy, which may give the best exposure and opportunity to debride the chest.

Sternal infections after cardiac surgery can also be a serious problem requiring drainage and

debridement. Ultimate repair of the defect following debridement may involve muscle or omental flaps

for sternal reconstruction.

Table 80-11 Mediastinal Tumors in Children

Chronic mediastinitis is a separate entity from acute mediastinitis and may arise from infectious

sources or autoimmune disorders. Patients may be asymptomatic until a mass effect is seen on their

mediastinal organs. CT scans are the best imaging modality to diagnose this condition, and surgery is

reserved only for diagnosis or in the end stages of the disease to relieve compression on other organs.

Sclerosing mediastinitis may be seen in patients with retroperitoneal fibrosis.81

Superior Vena Cava Syndrome

Superior vena cava (SVC) syndrome is a rare condition seen when a mediastinal mass compresses the

SVC resulting in facial and upper body edema. Only 15,000 cases per year are seen in the United States.

Patients may present with cough, dyspnea, or even stridor from upper airway edema. When patients

start to have symptoms, collateral venous drainage develops to drain into the azygos vein or inferior

vena cava. This process usually takes weeks. Malignant tumors are the most common cause, but venous

thrombosis and nonmalignant lesions cause upto one-third of cases. CT scans are the best diagnostic test.

Treatment is based on supportive care and addressing the underlying condition causing the obstruction.

If a malignant tumor is causing the obstruction, chemotherapy or radiotherapy may shrink the tumor

and lessen symptoms. Surgical resection with SVC reconstruction may be used in specific tumors such as

locally advanced thymomas. Angioplasty and stenting may be of benefit but is usually palliative.82

Although it is often felt to be an emergency, most cases of SVC syndrome have a slowly progressive

course. When a patient develops symptoms, supportive care, including possible intubation, will allow

time for collateral venous drainage to develop and symptoms to improve without other interventions.

Although the median survival is typically 6 months or less in patients with SVC syndrome from

malignant obstruction, some have seen long-term survivors when the primary tumors have responded to

appropriate treatment.83 When patients present with severe symptoms, it is a mistake to rush to surgical

intervention without a long-term plan. Symptoms should be managed and the etiology discovered and

treated appropriately.

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